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Thromb Haemost 1999; 82(S 01): 104-108
DOI: 10.1055/s-0037-1615564
DOI: 10.1055/s-0037-1615564
Commentaries
Submassive and Massive Pulmonary Embolism: A Target for Thrombolytic Therapy?
Weitere Informationen
Publikationsverlauf
Publikationsdatum:
14. Dezember 2017 (online)
Summary
Thrombolytic agents have been consistently demonstrated to dissolve pulmonary thrombi much more rapidly and effectively than heparin alone. Rapid resolution of pulmonary embolism (PE) is accompanied by a significant decrease in pulmonary artery pressure and an improvement in right ventricular function. However, it is no longer than 7 days until the findings of patients treated with heparin improve to a similar extent. Previous studies were not designed to determine whether this short-lasting difference in favor of thrombolysis can indeed affect the prognosis of patients with PE and thus justify the 1% (or even higher) risk of cerebral or fatal bleeding. Recently, two large registries demonstrated the importance of right ventricular dysfunction assessed by echocardiography as an independent predictor of mortality. Thrombolytic treatment was shown in one of these registries to be associated with a 50% reduction of death risk in clinically stable patients with right ventricular enlargement. It was thus possible to identify a group of patients with massive PE who are most likely to benefit from early thrombolysis. These findings now have to be confirmed by a prospective randomized trial which will compare thrombolysis with heparin alone in this high-risk patient population, focusing on clinical end points such as overall and event-free survival in the acute phase of PE.
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References
- 1 Hirsh J, Gale GS, McDonald IG, McCarthy RA, Pitt A. Streptokinase therapy in acute major pulmonary embolism: effectiveness and problems. Br Med J 1968; 4: 729-34.
- 2 Miller AH, Sutton GC, Kerr IH, Gibson RV, Honey M. Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism. Br Med J 1971; 2: 681-4.
- 3 Goldhaber SZ. Contemporary pulmonary embolism thrombolysis. Chest 1995; 107: 45-51S.
- 4 Hyers TM, Hull RD, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest 1995; 108: 335-51S.
- 5 ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thromboembolic disease. Chest 1996; 109: 233-7.
- 6 British Thoracic Society, Standards of Care Committee. Suspected acute pulmonary embolism: a practical approach. Thorax 1997; 52 (Suppl 4) S1-24.
- 7 Stein PD, Hull RD, Raskob G. Risks for major bleeding from thrombolytic therapy in patients with acute pulmonary embolism. Ann Intern Med 1994; 121: 313-7.
- 8 Verstraete M. Thrombolytic treatment. Br Med J 1995; 311: 582-3.
- 9 Dalen JE, Alpert JS. Thrombolytic therapy for pulmonary embolism: Is it effective? Is it safe? When is it indicated?. Arch Intern Med 1997; 157: 2550-6.
- 10 Goldhaber SZ, Vaughan DE, Markis JE, Selwyn AP, Meyerowitz MF, Loscalzo J, Kim DS, Kessler CM, Dawley DL, Sharma GVRK, Sasahara A, Grossbard EB, Braunwald E. Acute pulmonary embolism treated with tissue plasminogen activator. Lancet 1986; 2: 886-9.
- 11 Verstraete M, Miller GAH, Bounameaux H, Charbonnier B, Colle JP, Lecorf G, Marbet GA, Mombaerts P, Olsson CG. Intravenous and intra-pulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism. Circulation 1988; 77: 353-60.
- 12 PIOPED Investigators. Tissue plasminogen activator for the treatment of acute pulmonary embolism. Chest 1990; 97: 528-33.
- 13 Levine M, Hirsh J, Weitz J, Cruickshank M, Neemeh J, Turpie AJ, Gent M. A randomized trial of a single bolus dosage regimen of recombinant tissue plasminogen activator in patients with acute pulmonary embolism. Chest 1990; 98: 1473-9.
- 14 Dalla-Volta S, Palla A, Santolicandro A, Giuntini C, Pengo V, Visioli O, Zonzin P, Zanuttini D, Barbaresi F, Agnelli G, Morpurgo M, Marini MG, Visani L. PAIMS 2: Alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen Activator Italian Multicenter Study 2. J Am Coll Cardiol 1992; 20: 520-6.
- 15 Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, Taveira da, Silva AM, Come PC, Lee RT, Parker JA, Mogtader A, McDonough TJ, Braunwald E. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet 1993; 341: 507-11.
- 16 Come PC, Kim D, Parker JA, Goldhaber SZ, Braunwald E, Markis JE. Early reversal of right ventricular dysfunction in patients with acute pulmonary embolism after treatment with intravenous tissue plasminogen activator. J Am Coll Cardiol 1987; 10: 971-8.
- 17 Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper W. Comparison of alteplase-vs-heparin for resolution of major pulmonary embolism. Am J Cardiol 1998; 82: 966-70.
- 18 Dalen JE, Banas JS, Brooks HL, Evans GL, Paraskos JA, Dexter L. Resolution rate of acute pulmonary embolism in man. N Engl J Med 1969; 280: 1194-9.
- 19 Jardin F, Dubourg O, Gueret P, Delorme G, Bourdarias JP. Quantitative two-dimensional echocardiography in massive pulmonary embolism: emphasis on ventricular interdependence and leftward septal displacement. J Am Coll Cardiol 1987; 10: 1201-6.
- 20 Levine M. Thrombolytic therapy for venous thromboembolism. Clin Chest Med 1995; 16: 321-8.
- 21 Kanter DS, Mikkola KM, Patel SR, Parker JA, Goldhaber SZ. Thrombolytic therapy for pulmonary embolism. Frequency of intracranial hemorrhage and associated risk factors. Chest 1997; 111: 1241-5.
- 22 Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J, Just H, Kasper W. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry. Circulation 1997; 96: 882-8.
- 23 Urokinase in Pulmonary Embolism Trial: phase 1 results: a cooperative study. JAMA 1970; 214: 2163-72.
- 24 Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165-71.
- 25 Cannon CP, Goldhaber SZ. Cardiovascular risk stratification of pulmonary embolism. Am J Cardiol 1996; 78: 1149-51.
- 26 Research Committee of the British Thoracic Society. Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Lancet 1992; 340: 873-6.
- 27 Hall RJC, Sutton GC, Kerr IH. Long-term prognosis of treated acute massive pulmonary embolism. Br Heart J 1977; 39: 1128-34.
- 28 Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treatment for massive pulmonary embolism. Lancet 1994; 343: 576-7.
- 29 Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE. Mortality in patients treated for pulmonary embolism. JAMA 1976; 236: 1477-80.
- 30 Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz S, Thompson BT, Popovich J, Hobbins TE, Spera MA, Alavi A, Terrin ML. The clinical course of pulmonary embolism. N Engl J Med 1992; 326: 1240-5.
- 31 Urokinase in Pulmonary Embolism Trial: phase 2 results: a cooperative study. JAMA 1974; 229: 1606-13.
- 32 McIntyre KM, Sasahara AA. Hemodynamic and ventricular response to pulmonary embolism. Progr Cardiovasc Dis 1974; 17: 175-8.
- 33 Hull RD, Raskob GE, Coates G, Panju AA, Gill GJ. A new noninvasive management strategy for patients with suspected pulmonary embolism. Arch Intern Med 1989; 149: 2549-55.
- 34 Kasper W, Meinertz T, Henkel B, Eissner D, Hahn K, Hofmann T, Zeiher A, Just H. Echocardiographic findings in patients with proven pulmonary embolism. Am Heart J 1986; 112: 1284-90.
- 35 Kasper W, Geibel A, Tiede N, Bassenge D, Kauder E, Konstantinides S, Meinertz T, Just H. Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography. Br Heart J 1993; 70: 352-6.
- 36 Konstantinides S, Geibel A, Kasper W. Role of cardiac ultrasound in the detection of pulmonary embolism. Semin Respir Crit Care Med 1996; 17: 39-49.
- 37 Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of right ventricular afterload stress detected by echocar-diography in patients with clinically suspected pulmonary embolism. Heart 1997; 77: 346-9.
- 38 Lualdi JC, Goldhaber SZ. Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic implications. Am Heart J 1995; 130: 1276-82.
- 39 Goldhaber SZ, De Rosa M, Visani L. International Cooperative Pulmonary Embolism Registry detects high mortality rate. Circulation 1997; 96 Suppl I I-159. Abstract.
- 40 Konstantinides S, Geibel A, Olschewski M, Kasper W, Just H. Acute pulmonary embolism: the value of echocardiography for identification of high-risk patients. Circulation 1997; 96 Suppl I I-25. Abstract.
- 41 Jerjes-Sanchez C, Ram'rez-Rivera A, de Lourdes Garcia M, Arriaga-Nava R, Valencia S, Rosado-Buzzo A, Pierzo JA, Rosas E. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomized controlled trial. J Thromb Thrombolys 1995; 2: 227-9.